Metacarpal fracture/broken hand bone

Man, where do I even start...

Back on May 2, 2006, I broke a fifth metacarpal in my right hand. These are the X-rays taken immediately after the break:

http://img417.imageshack.us/img417/2...izacije3eo.jpg
http://img417.imageshack.us/img417/9...izacije7xq.jpg
http://img472.imageshack.us/img472/5...izacije8oy.jpg

My hand was immobilized right away..

On June 2, 2006, I saw an orthopedist who set the bone... and put me in a long arm splint.

By February 17, 2006, he had me in a full circular cast.

On March 3, 2006, that same doctor took the cast off, poked at my hand, and said, "looks great"... He told me to just exercise it in warm water. Didn't recommend any physical therapy... nothing... like he just wanted me out of his office ASAP..

Four days later, I went to my primary care physician and told him that things didn't look "great" to me. He sent me for an X-ray (since the orthopedist wouldn't...), and this is what happened after spending 25 days stuck in a cast...😠 😠 😠

http://img357.imageshack.us/img357/6...onskidanja.jpg
http://img429.imageshack.us/img429/2...onskidanja.jpg
http://img472.imageshack.us/img472/2...onskidanja.jpg

This could honestly go in a "Spot the Difference" section.

Yesterday, I saw a private specialist who actually "praised" the work his colleague did... Using ultrasound, he found a 27-degree bone angulation. He mentioned that while we could re-break it to set it properly, there’s a risk of creating a pseudoarthrosis at the fracture site, which might mess up the bone's ability to heal entirely. He also used ultrasound to find the beginning of callus formation around the break. He thinks the bone will remodel somewhat over time, but I'll be left with some permanent deformity.

His diagnosis is:
Fractura diaphyseos ossis metacarpalis V manus dex. cum angulationem
Contractura art. MCPH V manus dex, Postrumaticam
Tendovaginitis tendinis m. extensoris digiti minimi manus dex.

The cast is off now, and six days later, I can barely close my fist. There's a visible bump (check the photo) because of the angle, and the tendon keeps scraping against the damn bone whenever I try to make a fist.

-----------------------------------------------------------

I'm looking for advice. Can anyone suggest a
reputable orthopedist (maybe a hand surgeon?), because I really want a THIRD opinion! What have you guys dealt with? Should I re-break it or not?

Fracture of the fifth metacarpal shaft with angulation
Post-traumatic contracture of the fifth MCP joint (this happens when the joint stays immobilized and you stop moving it—which is why physical therapy is non-negotiable)
Tenosynovitis of the extensor digiti minimi tendon on the right hand

I have no idea how much cleaning is actually required or if it was too early to ditch the cast... all I know is the orthopedic surgeons at Mayo Clinic are top-tier; I can't speak for anyone else. If one of them handled your case, I'll back them up because, in my experience, every surgeon there is excellent... especially the professor if you saw him for hand specialization.

Look, it’s not about Salisbury... I live about 250 miles south of there on my little slice of paradise...😎 I'm sure the orthopedists in Salisbury are top-tier and this would never happen to them. The private orthopedic surgeon I saw—not the hack who messed me up—is based out of Venice. He just shook his head when he saw what that other idiot did to me...

But... I don't know if you actually clicked all those links and compared these two specific scans side-by-side?

Before immobilization:
http://img417.imageshack.us/img417/2...izacije3eo.jpg

After the cast came off:
http://img357.imageshack.us/img357/6...onskidanja.jpg

Honestly, I could have set this better myself.
I'm pissed, seriously 😠 ....

I don't care if I'm left with some level of deformity (Mount Everest, if it stays like this), I just need my hand to work again. Please, can you send me a private message with the name of that hand specialist professor? I am not leaving this to chance.

Yikes, that doesn't sound great at all. It sounds like you’re going to need more than just some solid physical therapy; you really ought to see a top-tier orthopedic surgeon too. Since you're down South, I'm not exactly sure who to point you toward locally... honestly, your best bet might be heading up to Washington, D.C.

I guess an angle somewhere between 20 and 30 degrees is probably considered acceptable

I don't have a whole lot to add to what Casey Cook10 already said.
Looking at that post-immobilization X-ray, it actually looks pretty decent. The angulation seems fine, there’s no significant bone shortening, and I don't see any obvious "collapse" at the MCP joint from what I can tell in the image.
If I were to add one thing, though, it feels like your private orthopedic surgeon was doing some major "overdiagnostics" just to pad the bill. Honestly, a follow-up X-ray is more than enough to check both the angulation and how the callus is forming. An ultrasound is basically useless here—trust me on this, I know what I'm talking about, ultrasounds just don't show bone detail properly.
And as for him claiming that the contracture happened because of the immobilization... haha, please. That's like saying the roads are wet after it rains.😈
Just stick to the basics: massage therapy, physical therapy, warm salt water soaks, and squeezing a tennis ball. If you do all that consistently for about twice as long as you were in the cast, you'll be just fine.🙂

Susan Martin24... any idea what the healing rate looks like for hand fractures? It seems like a tricky area to deal with since you rarely get back to 100% functionality.

My mom wiped out on some ice (!) and snapped her scaphoid. It didn't set right the first time, so they had to go back in to reset the bone. That was painful... haha.

Casey Cook10 said:An angle of 20-30 degrees is considered acceptable.

What kind of joint movement are we looking at after that kind of angling?

If I may ask, what actually qualifies as "acceptable" here?

When we talk about angulation, we aren't actually talking about the joint itself; it’s about the shaft of the bone. At the 4-to-5-week mark, that area isn't fully set yet. Basically, the pulling forces from your muscles will naturally work to "straighten out" the bone over time. That 20-to-30-degree angle will eventually smooth out as the bone undergoes ossification and remodeling, which usually takes anywhere from three to six months.
It makes total sense that movement in the MCP joint is limited, but honestly, it’s not really because of the fracture mechanics—it’s because of the immobilization.
See, keeping those bone fragments in close contact and staying still is a absolute prerequisite for forming a callus and getting the bone to heal properly. If those pieces keep shifting around instead of staying put, you run the risk of developing a nonunion, or pseudoarthrosis. It’s one of those classic medical catch-22s: you’re treating the break, but in doing so, you might end up stiffening the joint.
But that’s exactly why physical therapy exists. The whole point of PT is to use specific, controlled movements to apply those beneficial pressure and tension forces that help straighten the bone while simultaneously working on joint mobility.
There’s also a pretty big divide in how fractures are handled depending on whether you're talking to a surgeon or an orthopedist. In my experience, orthopedists tend to give much less credit to the importance of a Physiatrist and physical therapy compared to us, especially when we're dealing with fractures being managed conservatively. 😈

It’s pretty weird to me that this kid hasn't even heard of physical therapy...
meaning they just never told him.

And why’s that, kiddo? I didn't get the vibe that he was some little brat, unless you're just being way too old-school about it, huh?

Man, I went through the exact same thing. My X-rays look almost identical to yours. I started out at the local church, but they totally botched everything there, which landed me in trauma surgery over at Drašković... long story short, even after all the physical therapy, I still can't fully make a fist today.

I went through something pretty similar myself—ended up with a subcapital fracture of the fifth metacarpal. To make matters worse, the folks over at the local VA hospital did a pretty lousy job setting it. We’re talking a forty-degree angle that looked straight-up wrong. But, as Susan Martin24 pointed out, the bone actually started correcting itself slightly just from the natural movement. I’ve still got a bit of a bump there, but honestly, my hand works perfectly fine. My big takeaway? There are zero hard-and-fast rules in medicine; everything is wildly different from one person to the next.

Andrew Brown13 said:man, I had the exact same thing happen. My X-rays look pretty much identical. I ended up at Holy Spirit first, but they totally botched it there, so I had to go to the trauma center over at Drašković for surgery. All in all, even after all the therapy, I still can't fully make a fist today.

Man... glad I'm not the only one... (no offense intended). When you say the X-rays are almost identical, are you talking about yours or mine that I posted?

When did you break it, how many days were you at Holy Spirit, and how long after that did you head to the trauma unit at Drašković?

It's been 42 days for me since the break, and 16 days out of the cast.
Even though I can squeeze my hand, it just isn't the same—it still doesn't work like it used to. Strength is coming back slow. Interestingly, I feel like my left hand is taking over for the right, even though I can use my right. And my right hand used to be my alpha and omega.

silentmason15 said:I had a similar situation, broke my 5th metacarpal subcapitally. They set it poorly at Drašković, maybe a 40-degree angle, but like Susan Martin24 said, the bone corrected itself slightly through movement. I have a bump now, but function is normal. Conclusion: there are no rules in medicine, a lot of it is just down to the individual.

silentmason15, I’m going to ask you the same thing because I'm really curious: How long ago did this happen to you, how long were you in a cast, when did your strength start returning, and how long did it take for that bump to start shrinking?

I found some info online stating that the average angulation for fifth metacarpal neck fractures is about 39 degrees, which means you're pretty much right around the average.

In my case, it was what they call a fifth metacarpal mid-shaft fracture—meaning the bone snapped right in the middle—and for that type of break, the tolerance for angulation is way lower (or so I read). My ultrasound showed 27 degrees.
And my Physiatrist just shook her head when she saw the X-rays before and after the cast. She said they should have opened it up immediately after the break and put in a plate and screws, and it would've been a non-issue...

But damn... In America, it's just luck... either you run into a doctor who actually knows their stuff and loves what they do, or you get stuck with some incompetent hack who has chronic PMS and a medical degree.😠

P.S. Here's an interesting article and some perspective on the choices people make in life. This guy had the exact same break we did...

http://www.disseminate.com/archive/2..._04_index.html

Man, it’s such a toss-up... In the US, you basically just roll the dice on whether you'll land a doctor who actually gives a damn about their patients, or if you'll end up stuck with some local grease monkey who happens to have a medical degree and a permanent case of PMS... 😠

Look, honey, it doesn't work like that everywhere in America either. If you took a little trip around the world, you'd realize we aren't any better or worse than anyone else out there... 😈
Honestly, I’d go as far as to say we’ve got it pretty easy, considering the circumstances most people are working under.... 😬

Susan Martin24 said:I’d go as far as saying we’re being incredibly generous, considering the conditions most people work under... 😬

🙏

McQueen said:In my case, it was what they call a fifth metacarpal mid-shaft fracture—basically, the bone snapped right in the middle, and I think I read somewhere that you have way less wiggle room for angling with that kind of break. My ultrasound showed it at 27 degrees.

Not to be repetitive, but honestly, 20 to 30 degrees is usually fine. I'm just curious about the specific threshold where you read it was unacceptable. And as for using ultrasound to diagnose bone structures... 🙄
Well, if you really want to know, someone definitely took your money without even blinking... since you're basically picking at my words here.

McQueen said:The physiatrist just sort of shook her head when she saw the X-rays from before and after the cast was applied. She mentioned that they probably should have performed an open reduction immediately after the break and set it with a plate and screws, and then it would've been all settled...

It’s the same story here, unfortunately—pretty typical for the medical system in America. You see specialists who don't really know what other departments do, yet they feel the need to comment on everything loudly right in front of the patient. If she had just called her colleague to ask why things weren't handled differently or why a certain procedure wasn't done... instead, she just talks. I can't tell you how many times I've called colleagues to ask for advice, point out a slip-up, or maybe just yell a bit when they start getting too arrogant. But I'm not going to act surprised in front of a patient and wonder which technician messed up; I'll just do whatever I can for the patient, and eventually, those mistakes catch up to people.

Look, man, I hate to say it, but I know plenty of colleagues whose main goal is just to look like some kind of hero in front of the patient. They act all super attentive and caring just hoping the patient will feel obligated to tip them or show some extra gratitude later 🤮.
Not too long ago, I had this one patient who was skiing in Canada and took a nasty fall, breaking his clavicle. It was a classic fracture right at the border of the medial and lateral thirds, but the displacement was huge—about 4 to 5 cm. He’d been treated in Charleston, but they basically just gave him some basic taping instead of actually fixing the bone with plates and screws.
Clinically speaking, it looked terrible—there was about a 7 cm defect in the shoulder plateau, the whole shoulder was drooping, and he'd lost about 90% of his range of motion on the injured side.
He ended up seeing me just by chance (the guy's originally from California) through an acquaintance of a nurse who works with us, and it was about a week after the injury happened.
Since my focus is mostly on small joints and hands rather than major trauma, I tried to reduce it myself, but it just wouldn't budge. I put him in a Cellacare Clavicula rigid brace and tightened it as much as I could to see if we could gain any length back... but I was honest with him. I told him I really thought he’d need surgery because, honestly, without it, there was almost no way it would heal properly without forming a pseudoarthrosis.
So, I suggested he go get some X-rays in San Francisco and see a trauma specialist.
Anyway, the guy got his scans done, and two weeks after the fracture, there wasn't even a hint of callus formation—just accelerated resorption at the broken ends. The orthopedic surgeon who saw him (who, to be fair, had recently been in a bad car wreck and was in a coma for fifteen days—so you can forgive him a little bit, though I guess the alcohol didn't help matters either) basically yelled at him: "WHAT ARE YOU DOING HERE? WHAT KIND OF IDIOT TOLD YOU THIS WASN'T A PROBLEM??!!?? EVERYTHING IS FINE, GO HOME, AND COME BACK IN TWO WEEKS..."
The guy came back to show me the results, but clinically, nothing had changed. I eventually recommended he head over to Carmel-by-the-Sea, where he finally ended up getting the surgery.
After that, I have no idea what happened. 🙂

doc_1 said:Not to repeat myself, but 20-30 degrees is acceptable. I’m just wondering how much is okay in the context you read that. And regarding ultrasound for bone structure diagnostics 🙄

According to MC Hammer et al 1987, a simple splint is sufficient if volar displacement causes angles a) under 20 degrees at the second and third metacarpal neck b) under 30 degrees at the fourth, and c) under 45 degrees at the fifth. These figures only apply to angulation at the neck. The further down the shaft the fracture is, the less angular deformity you can actually tolerate (Bowen et al 1988).

http://www.diavlos.gr/orto96/goula.htm
It wasn't my neck, it was mid-shaft, so the break went right through the middle. That explains the massive deformity and why the joint looks like it's "diving" down and inward. Pythagorean theorem, side b.

doc_1 said:You wouldn't even ask that, since someone would have snatched the cash right out of your pocket before you could blink... since you're already nitpicking me

Honestly, I don't give a damn about the money. I'm talking about health here, not bank accounts. I was desperate, which is why I went to a different orthopedic surgeon, but by then it was too late. Whether he was overdiagnosing or if ultrasound is actually useful for this... you guys say it isn't... fine, but I didn't know that at the time! Again—money isn't the point.

This "expert," the guy who put me in the cast... fourteen days before taking it off, he wrote:

"Follow-up in two weeks, then X-ray"

Two weeks passed. He took the cast off, felt it, and said: "GREAT."
And he didn't even send me for an X-ray despite me asking... He just said: "No need, why bother irradiating your hand for nothing?"

Why wouldn't he send someone for an X-ray after they've spent 25 days with their right arm stuck in a cast?

Because the "expert" knew he screwed up. He just wanted me out of his office as fast as possible. When I asked if I could wash my hand, he started screaming at me about what I thought I was doing and told me this isn't a public restroom. Then his nurse grabbed my left arm and pulled me into another room, where she started washing it despite me resisting. He just kept yelling at her that he'd dock her pay and all that, but she didn't seem to care. She just snapped back: "Go ahead and do it then."

doc_1 said:This is also unfortunately typical in our medical system. People who don't understand other specialties yet feel entitled to comment on them, especially in front of patients. If she hadn't called her colleague to ask what was being done or why something wasn't performed, etc. I have hundreds of examples where I've called colleagues to ask questions, warn them about mistakes, or tell them to pipe down when they get arrogant. But I won't act surprised in front of a patient and ask which "master" treated them; I'll just do whatever I can for the patient, and eventually, every mistake catches up to them.

Other orthopedists and physical therapists have played the finger-pointing game too. Why didn't she call him? Because I told her straight up that I’m done seeing him. As for making comments right in front of a patient... sounds like they're just hiding behind a wall of silence to me.
Is the Hippocratic Oath just an excuse to hide behind that wall?

"...Whatever I see or hear in the course of my profession, even outside of it, which ought not to be publicly disclosed, I will hold secret."

I’d say yes. A lot of you are probably going to come for me, but fine, let it happen. Personally, I think the Hippocratic Oath is just an outdated relic that doesn't belong in the modern world. That's why the Declaration of Geneva from 1948 exists. Does "professional brotherhood" mean covering for each other when someone messes up?

I've already lost one family member to medical malpractice (spent two weeks at one hospital without a single diagnosis, then got moved to another where they figured it out on day one. They tried to force-feed him through a tube—four people had to pin his arms and legs down just to get it in. A few hours later, he started coughing up blood and was gone.)

Another family member is still alive, but 90% disabled. She underwent surgery (after 29 days of useless testing) under suspicion(!) of a malignancy. Grand total: they removed two and a half organs. The pathology report showed nothing but inflammation that should have been treated with penicillin. The whole show was run by some famous doctor who used to be all over the news.

Neither of them were saved by blue envelopes (which, by the way, kept sliding under the table more than once).
And if you think I won't hold him accountable for every single mistake, you're dead wrong. Totally wrong.

I don't want to sound bitter, but life has taught me to take everything a doctor says with a grain of salt.

New Yorker2 said:Look, I see this all the time with colleagues—people who are more concerned with looking like heroes in front of their patients than actually doing the right thing. They play the "super caring, ultra-engaged" role, hoping the patient will somehow feel obligated to reward them for the drama. 🤮.
Not too long ago, I had a patient who took a nasty fall while skiing in Canada and broke his clavicle. It was a classic fracture right on the border of the medial and lateral thirds, but the displacement was huge—about 4 to 5 cm. He was treated in Venice, where they basically just slapped some hardware on him instead of using proper plates and screws.
Clinically, the situation was a disaster: he had about a 7 cm defect in the shoulder plateau, significant shoulder drop, and lost about 90% of his range of motion on that side.
He ended up coming to me by chance—he’s from California and is an acquaintance of a nurse who works at our clinic—about a week after the injury happened.
Since my specialty is small joints and hands rather than major trauma, I tried to reduce it myself. It didn't work. I put him in a rigid Cellacare clavicle brace and tightened it as much as possible to try and gain some length, but I was honest with him: I told him surgery was likely necessary because, without it, there was a massive risk of non-union.
I advised him to get X-rays in San Francisco and see a trauma specialist immediately.
Anyway, he got the imaging done. Two weeks after the break, there was zero sign of callus formation; instead, the bone ends were just resorbing faster. The orthopedic surgeon who saw him (this guy had recently been in a bad car accident and spent fifteen days in a coma—so, granted, you can somewhat excuse him, though the alcohol didn't help either) looked at it and yelled: "WHAT ARE YOU DOING HERE? WHO ON EARTH TOLD YOU THIS WAS FINE??!!?? EVERYTHING IS PERFECT, JUST GO HOME AND COME BACK IN TWO WEEKS..."
The guy came back to show me the results, and clinically, nothing had changed. I eventually recommended he head over to Carmel-by-the-Sea, which is where he finally ended up getting the surgery.
After that, I lost track of what happened. 🙂

Please check my previous question under the Rheumatoid Arthritis thread...